Search

BACKGROUND Most umbilical hernias spontaneously close by 3-5 years of age; therefore, surgical repair is considered only in children whose hernias have not closed by this point. At present, adhesive strapping is not the preferred treatment for umbilical hernias because of the lack of supporting evidence regarding its efficacy, and its association with skin complications. This aim of this study was to examine umbilical hernia closure on ultrasonography, and reassess the merits of adhesive strapping. METHODS Between January 2013 and December 2014, 89 infants underwent adhesive strapping for umbilical hernia. The strapping was changed once a week. The diameter of the hernia orifice was measured on ultrasonography every 2 weeks until closure. The closure speed (CS) of the hernia orifice was compared between the infants treated with adhesive strapping and those undergoing observation alone. The association between CS and birthweight, gestational age, diameter of the hernia orifice, and timing of treatment (before 12 weeks of age vs between 12 and 26 weeks of age) was also analyzed. RESULTS Closure was achieved after 2-13 weeks of strapping in 81 infants (91%), and the likelihood of closure was not affected by the diameter of the hernia orifice, gestational age, or the timing of treatment. The mean CS of the infants treated with adhesive strapping was significantly faster than that of the infants undergoing observation alone (2.59 vs 0.37 mm/week, P < 0.05). Adhesive strapping was discontinued in five of the 89 infants (5.6%) due to severe skin complications. CONCLUSION Adhesive strapping promoted early spontaneous umbilical hernia closure compared with observation alone, regardless of the diameter of the hernia orifice. Adhesive strapping is an effective alternative to surgery and observation.

Iliopsoas abscess (IPA) is uncommon in childhood and very rare in the neonate and infant. We present a case of IPA after an umbilical granuloma in an infant. A baby girl with a birth weight of 2,970 g was born at thirty-seven weeks and two days gestation by Caesarean Section. On the fourteenth day after birth, her umbilicus was wet and developed the granulomatous formation. At two months of age, she presented with right leg and groin swelling with mild bluish discoloration and without fever. She had poor movement of her right leg and showed apparent discomfort. Her umbilicus was dry and there was no granulomatous material. Ultrasonography and computed tomography demonstrated an iliopsoas abscess in the right position. Therefore, an extraperitoneal surgical drainage was performed, aspirating yellowish pus. Culture of the purulent material revealed Staphylococcus aureus. Systemic antibiotic therapy was continued for ten days. After three days of drainage, full-range motion of the right leg was gained, and then after eleven days, CT findings comfirmed the disappearance of the iliopsoas abscess. IPA is extremely rare and it is difficult to diagnose. However, it should be included in the differential diagnosis of an infant with poor leg movement and swelling of the groin to the femur.

Percutaneous transesophageal gastrotubing (PTEG) was performed in a 12-year-old boy with severe motor and intellectual disabilities (SMID) whose trunk was severely deformed. He was referred to our pediatric surgical service for tracheostomy and percutaneous endoscopic gastrostomy (PEG) due to respiratory failure and difficulty in oral intake. Considering that the patient could not maintain a supine position, a standard gastrostomy procedure, either open or endoscopic, could not be performed. Moreover, postoperative care for gastrostomy would be challenging. Therefore, PTEG through the stretched anterior neck was indicated. PTEG involves creating an echo-guided percutaneous esophageal puncture under fluoroscopy to introduce a feeding tube from the esophagus into the stomach. PTEG has not been used in pediatric patients yet however, the procedure seems to be an effective alternative route of enteral feeding in children with SMID who cannot undergo PEG, as demonstrated in the present report.

Background Although complete excision is the standard treatment for pyriform sinus fistula (PSF), it has recently been suggested that chemocauterization via the internal orifice of the fistula could be an effective non-invasive treatment for the condition. The present report describes the details of our experience with and the efficacy of endoscopic chemocauterization for pediatric PSF. Method Between January 2010 and June 2015, four patients were diagnosed with PSF and scheduled to undergo endoscopic chemocauterization. Under general anesthesia, trichloroacetic acid (TCA) solution was endoscopically injected through the opening of the fistula using a fine plastic tube. Esophagogram was obtained at 3 weeks after the procedure to search for recurrence. Complete closure of the fistula was confirmed on endoscopy at 2–3 months after chemocauterization. Results Two of the four patients were treated once, and the remaining patients required further chemocauterization procedures. No recurrence developed in any patient after it had been confirmed that the fistula's internal orifice had been obliterated. Some transient complications, such as sore throat, nausea or temporary vocal fold paresis, occurred. Conclusion Chemocauterization with TCA seems to be a useful first-choice treatment for PSF.

We present an unusual case of acute abdomen caused by torsion of an acces- sory spleen with situs inversus in a child. A three-year-old girl was admitted to our hos- pital with an 11-day history of right flank pain with fever. Her medical history revealed an operation of coarctation of the aorta with situs inversus at one month of age. Physi- cal examination revealed a right flank mass and tenderness. A contrast-enhanced CT scan showed a normally enhanced small spleen in the right upper quadrant and a 7.0 6.0 3.5 cm, hypodense, marginal enhancing mass in the right midabdomen adjacent to the intestine. An emergency laparotomy was decided upon with a preoperative diagno- sis as an acute abdomen. During surgery,a mass was found under the greater omentum and two accessory spleens of 1.5 cm in diameter were found surrounding the main spleen. Several loops of bowel were adherent to the mass. The loops of bowel were dissected away. A pediculated congested mass was observed as an accessory spleen emerging from the greater omentum. The mass was twisted on its vascular pedicle and strangulated. The necrotic mass was removed and the postoperative recovery was uneventful. Though tor- sion of an accessory spleen is extremely rare, it should be considered in the differential diagnosis of acute abdomen in childhood. J. Med. Invest. 59 : 220-223, February, 2012

Most umbilical hernias spontaneously close by 3-5 years of age; therefore, surgical repair is considered only in children whose hernias have not closed by this point. At present, adhesive strapping is not the preferred treatment for umbilical hernias because of the lack of supporting evidence regarding its efficacy, and its association with skin complications. This aim of this study was to examine umbilical hernia closure on ultrasonography, and reassess the merits of adhesive strapping.Between January 2013 and December 2014, 89 infants underwent adhesive strapping for umbilical hernia. The strapping was changed once a week. The diameter of the hernia orifice was measured on ultrasonography every 2 weeks until closure. The closure speed (CS) of the hernia orifice was compared between the infants treated with adhesive strapping and those undergoing observation alone. The association between CS and birthweight, gestational age, diameter of the hernia orifice, and timing of treatment (before 12 weeks of age vs between 12 and 26 weeks of age) was also analyzed.Closure was achieved after 2-13 weeks of strapping in 81 infants (91%), and the likelihood of closure was not affected by the diameter of the hernia orifice, gestational age, or the timing of treatment. The mean CS of the infants treated with adhesive strapping was significantly faster than that of the infants undergoing observation alone (2.59 vs 0.37 mm/week, P0.05). Adhesive strapping was discontinued in five of the 89 infants (5.6%) due to severe skin complications.Adhesive strapping promoted early spontaneous umbilical hernia closure compared with observation alone, regardless of the diameter of the hernia orifice. Adhesive strapping is an effective alternative to surgery and observation.

Purpose We present a new fistulectomy method for the second pharyngeal arch remnants. Materials and Methods Between 1991 and 2003, 4 patients have been treated with a new fistulectomy method. Surgical Procedure Under general anesthesia with nasotracheal intubation, the neck and mouth are prepared as one operative field. A nylon thread is inserted into the cervical opening. On the oral site of the nylon thread, a small gauze ball is tied and gently pulled from the neck site. At both opening sites of the fistula, a very small incision around the nylon thread is performed. Using the nylon thread as a guide, a fistulectomy is carried out. Results In all 4 patients, no complications have occurred during and after the fistulectomy. No recurrences were seen during 15 months to 9 years. Conclusions This is a simple and useful procedure for the treatment of second pharyngeal arch remnants. It produces an excellent cosmetic result compared with the standard method because only one small incision is necessary.

A 62-year-old man underwent endoscopic mucosal resection for early gastric cancer. The follow-up computed tomography revealed biliary dilatation. The tumor was located in the lower bile duct with biliary dilatation, and no evidence of metastasis in other organs was noted. The patient underwent subtotal stomach-preserving pancreatoduodenectomy with pancreaticogastrostomy and Billroth I anastomosis. At 13 months after the operation, gastrointestinal endoscopy revealed a tumor lesion in the pancreaticogastrostomy site. Computed tomography revealed that the lesion was low enhanced in the pancreaticogastrostomy site and there was no evidence of other distant metastasis. Partial pancreatectomy was performed. Pathological findings of the tumor in the stump of the pancreas revealed findings similar to that of primary biliary carcinoma. Apparently, the patient was diagnosed with recurrence of bile duct cancer via the pancreatic duct. The patient underwent adjuvant chemotherapy for one year subsequent to partial pancreatectomy as the second operation. For 40 months after the second operation, there has been no evidence of recurrence of cancer.

D-lactic acidosisは,通常検出されないD型乳酸の増加によりアシドーシスを惹起する疾患で,短腸症候群の患児に稀に発症する.われわれは,新生児期に回腸閉鎖のために回盲弁を含んだ小腸広範囲切除術(残存小腸75cm)を施行した患児に,代謝性アシドーシスを併発し, 2回目の発症時にD-lactic acidosisと診断した症例を経験したので報告する.本症例においては, D型乳酸の測定は行っていないが,発症時の便培養においてLactobacillus fermentumが90%以上を占めており,これが診断の根拠となった.治療法は,重曹の内服を3ヵ月間行った.治療開始以降,便の細菌叢の正常化を認め,その後同様の症状の出現を認めなかった.

Hirschsprung病に合併した閉塞性鼠径ヘルニアの小児例を報告する.先天性魚鱗癬を伴った未熟児の男児が紹介された.生後4日目から腹満が続きHirschsprung病と診断した.生後20日,両側鼠径ヘルニアを認めた. 9カ月時,重篤な便秘と両側陰嚢の腫脹を認め再入院した.注腸透視にて左側陰嚢内に極めて硬い糞塊を含んだS状結腸が存在していることが判明した.硬い糞塊を含んだS状結腸の整復を試みたが糞塊が硬く疼痛を訴えできなかった.緊急鼠径ヘルニア手術時, S状結腸内の硬い糞塊は小さい糞塊に分割して連続する腹腔内の結腸に整復した.最終的に閉塞性ヘルニアと診断した.術後経過は異常なかった. 22カ月時, Duhamel変法にてHirschsprung病の根治術を施行した. 29カ月時,原因不明で自宅で死亡した.剖検はできなかった.

We describe an extremely rare case of subcapsular rupture of the liver associated with hemophilia A in a neonate. Although, the neonate was in good condition after birth, at 13 hours, he became pale and his abdomen distended. At 17 hours after birth, an emergency laparotomy was performed. The subcapsular rupture of the left side of the liver was found. The ruptured area was closed with a continuous suture, and additional mattress sutures with pledget provided satisfactory hemostasis. On the second day after the operation, relaparotomy was done because recurrent bleeding was suspected. There was no bleeding from the sutured liver. Oozing was found at the suture line on the abdominal wall. An additional postoperative observation was a decrease of factor VIII less than 1%, and hemophilia A was confirmed.

We report 110 cases of hypertrophic pyloric stenosis which were operated on at the Department of Surgery of National Kagawa Children's Hospital from July 1974 to July 1994. There were 87 males and 23 females, and the male-to-female ratio was 3.8:1. The majority were the first-born and second-born children. The most frequent incidence in birth weight was recognized between 3001 and 3500g, and the low birth weight infants were seen in only 5 cases. The average onset of vomiting was 21st day in the mature infants and was 28th day in the low birth weight infants. The mean size of pyloric tumors was 23.4×16.7×4.7mm. The average episodes frequency of postoperative vomiting was 4.5 times, the mean duration of the postoperative vomiting was 2.4 days, and the averaged hospital stay was 16.4 days. The case of death was not observed. The strong correlation between seurm Cl value and Na, K, pH and B.E. values was observed. A recent shortening of preoperative symptomatic period is closely related to an increasing of mild cases. On the other hand, it is suggested that, in severe cases, not only correction of the water and electrolyte inbalance but also correction of blood Hb and protein are needed.

Recent experience with a pediatric case of perforation of the cervical esophagus due to accidentaly ingested pool cleaner which caused mediastinitis is described here, with a review of the literature. A 12-year-old girl who happened to ingest a pool cleaner tablet was referred to the hospital because of dyspnea. From an esophageal contrast examination, she was diagnosed as having a perforation of the cervical esophagus accompanied by mediastinitis. Primary closure of the perforation and left cervicomediastinal and paraesophageal drainage were carried out. After the operation right mediastinitis became worse. Seventeen days following the injury, the right cervicomediastinal and paraesophageal drainage was performed, but the inflammation advanced. Twenty-seven days after the injury, esophageal drainage with a T Tube, paraesophageal and right cervicomedias-tinal drainage with a Duple drain were performed. The inflammation gradually subsided as the paraesophageal and mediastinal continuous lavage with povidone iodine solution were applied.

The author describes an extremely rare case of coexistence with imperforate anus, malrotation, and double zonal aganglionosis. A colostomy was performed on a 2-day-old male infant at the proximal sigmoid colon, because the finding of an invertgram revealed an intermediate type of imperforate anus. At the age of 1 month, a distal colostogram showed the low type without fistula. An upper gastrointestinal series revealed malrotation. At 4 months of age, Ladd's procedure and an anoplasty were done. The function of the colostomy was not good. At laparotomy, a narrowing terminal ileum was removed for being a suspected intestinal obstruction. Histologic findings of the removed ileum revealed aganglionosis. A rectal suction biopsy showed the positive finding of acetyl cholinesterase staining. Therefore, the patient was diagnosed with extensive aganglionosis. At 9 months of age, a 1-stage ileoendorectal pull-through with a right colon onlay patch was performed. Histologically, a skipped ganglionic bowel segment at the right colon, a double zonal aganglionosis, was found among the extensive aganglionosis. Although the ganglionic right colon was used for the colon patch, which was placed for antiperistaltic movement, postoperatively the bowel function was excellent. The author herein describes an extremely rare case of coexistence of imperforate anus, intestinal malrotation, and double zonal Hirschsprung's disease. A case with this association, to the author's knowledge, has not been reported previously in the literature.

Heterotopic pancreas (HP) is rarely recognized during surgery. Many reports concerning this anomaly are simple case reports. We herein review our experiences with HP. We retrospectively investigated cases of HP from April 1975 to September 2006. We discussed the frequencies in the laparotomized patients, and patient’s age, gender, operative indication, location of HP, post-operative diagnosis and pathology. A total of 12 patients with HP, 3 boys and 9 girls, aged 1 day to 10 years of age were investigated. Ten patients had one pattern of HP and the remaining two had more than one. The locations of the HP were as follows: Meckel’s diverticulum, 4; stomach, 3; duodenum, 3; jejunum, 3; and ileum, 2. Only in one patient HP had caused an intussusception. The remaining 11 cases were identified incidentally during the operation. In 11 of 12 patients, HP was removed without post-operative complications. Classification of pathologies according to Heinrich is as follows: type I, 4; type II, 4; type III, 2 and unknown, 2. Patients with HP are usually asymptomatic. However, HP caused an intussusception in our series. Incidental HPs should be removed whenever identified during laparotomy.

Intussusception is one of the common causes of intestinal obstruction in early childhood. Although a genetic predisposition has been suggested in some cases, its etiology is considered to be incidental, and it has not been traditionally regarded as having any genetic basis. Authors report on cases of so-called idiopathic intussusception that demonstrate a strong familial tendency.We reviewed medical records of idiopathic intussusception reduced in our institute between 1975 and 2004. There were 564 patients. Their parents and/or grandparents were interviewed directly or by telephone about the occurrence of familial intussusception.A family history of idiopathic intussusception, including third-degree relatives, was noted on 39 pedigrees. Occurrences between father and son were 1, mother and son 4, mother and daughter 2, mother and son and daughter 1 (sibling), siblings 10, sibling and cousin 1, uncle or aunt and nephew or niece 6, uncle and nephew and niece (cousin) 1, and cousins 13. Among 564 patients with idiopathic intussusception, 20 patients, both of 6 pairs of siblings and both of 4 pairs of cousins were treated in our institute. So in 554 pedigrees of idiopathic intussusception, the incidence of familial intussusception, including third-degree relatives, was estimated to be 7.0% or 1 in 14.2 cases.We concluded that hereditary predisposition, such as anatomical basis, may be considered as an etiological factor in many cases of idiopathic intussusception. In these predisposed families, if they have inducements such as viral infections as the acquired agents, intussusception will occur very easily.

Menkes' kinky hair disease is a rare congenital disorder of copper metabolism with X-linked recessive inheritance. It is well known that it is frequently associated with urologic abnormalities. The authors experienced three such cases, but each of them was different. Multiple bladder diverticula, right vesico-ureteral reflux, and right hydronephrosis were noted on the first baby boy. In the second case, hematomas in the left kidney, pelvis, ureter and the adipose capsule, which were thought to be the abnormality of vessels, were noted in the neonatal period. In the third body, multiple bladder diverticular were noted at the age of 1 year. One year, 10 months later, a spontaneous rupture at the huge diverticulum occurred.

A variety of complications can occur following open heart surgery. A remarkable progress in antibiotics has been achieved nowadays, but on the other hand, we are facing a new complication of the mycotic infection. This time we experienced an infant with congenital heart disease (ventricular septal defect) associated with unilateral renal candidiasis after open heart surgery, which was successfully managed by ultlasonography-guided percutaneous nephrostomy. A 3 day old female infant was referred to the hospital because of heart murmur and tachypnea. The patient diagnosed as ventricular septal defect based on ultrasonographic and intracardiac cathether examinations. Open heart radical operatin was performed. On and after 50th day following the operation, high fever over 38°C continued and a mass locating in the right upper abdomen was palplate. The patient did not respond to chemotherapy. Abdominal CT and ultrasonography revealed a remarkably swoolen left kidney and dilation of the renal pervis. Obstructing candidiasis of the urinary tract was suspected. Ultrasonography-guided percutaneous nephrostomy was performed, and soft material filling the urinary pelvis was removed. Histologically the material was diabnosed as fungal clot. Percutaneous nephreostomy with antegrade amphotericin B irrigation, coupled with systemic antifungal therapy, was effective. This regimen would be the mainstay of treatment.

In this report, we describe the first case of recurrent perforations of viscus due to ventriculoperitoneal shunt for the treatment of hydrocephalus. Based on our own experience and a survey of literature, we suggest that perforation of the gastrointestinal tract should be suspected in patients with ventriculoperitoneal shunt, particularly when abdominal symptoms or ventriculitis are presented. To manage this complication, at the first perforation in the present case, a fibrin sealant was effective for closure of the perforated stomach wall. At the second perforation, when laparotomy was performed, we could not find any abnormality in the abdominal cavity except for a sheath and slight omental adhesions near it.

A child developed bacterial meningitis and shunt dysfunction 2 years after the insertion of a ventriculoperitoneal shunt for posttraumatic hydrocephalus. The distal end of the shunt catheter had penetrated the gastric wall. We found no other report of intragastric shunt catheter migration with successful treatment

A case of chylothorax following Bochdalek herniorrhaphy in an infant is presented. To our knowledge, it is only the third case to be reported in the literature.